Management of Penetrating Neck Trauma

Shashidhar S. Reddy, MD, MPHShawn D. Newlands, MD, PhD

Types of Weapons! Low velocity – knives, ice picks, glass! High velocity – handguns, shotguns, shrapnel

Guns

Ballistics

Ballistics

Ballistics

Anatomy

Anatomy

Incision for Neck Exploration:

Incisions for Neck Exploration:

Incidence and Mortality

Initial Management

Signs of Injury:

Signs of Injury:

Management of the Stable Patient:The Old Standard:

The Old Standard:! Based on wartime experiences! Fogelman et al (1956) showed that immediate neck

exploration led to better outcomes in study group for vascular injuries.

! Led to rate of negative neck explorations in > 50%! Arteriogram slowly began to gain acceptance as

screening tool before exploration, especially for zone 1 and 3 injuries (hard to detect on physical).

Arteriogram! Zone 1 and Zone 3 vascular injuries are difficult to

visualize by physical exam, making arteriogram useful in these patients.

! Flint et al (1973) reported absence of P.E. findings in 32% of pts. with major zone 1 vascular injury.

! Arteriogram can be accompanied by embolization.

A Newer Algorithm

Mansour et al 1991 retrospective study

Newer Algorithm (Mansour)! 63% of the study population was in the observation group.! Entire study population had a mortality of 1.5%, similar to

those in more rigorous treatment protocols.! Similar results obtained in other large studies with similar

protocols (e.g. Biffi et al 1997).! Still uses the Arteriogram in asymptomatic patients with

zone 1 injury.

Points of Controversy:! Most trauma surgeons accept observation of select

patients similar to the Mansour algorithm.! Study by Eddy et al questions the necessity for

arteriogram / esophagoscopy in asymptomatic zone 1 injury (use of P.E. and CXR resulted in no false negatives).

! Other noninvasive modalities than arteriogram exist for screening patients for vascular injury.

CT scan! Can aid in identifying weapon trajectory and

structures at risk.! Should only be used in stable patients.! Gracias et al (2001) found that use of CT scan in

stable patients was able to save patients from arteriogram indicated by other protocols 50% of the time and avoid esophagoscopy in 90% of tested patients who might otherwise have undergone it.

Duplex Ultrasonography! Requires the presence of reliable technician and

radiologist.! A double blinded study by Ginsburg et al (1996)

showed 100% true negative, 100% sensitivity in detecting arterial injury, using arteriography as the gold standard.

Management of Vascular Injuries:! Common carotid: repair preferred over ligation in

almost all cases. Saphenous vein graft may be used. Shunting is rarely necessary. Thrombectomy may be necessary.

! Internal carotid: Shunting is usually necessary! Vertebral: Angiographic embolization or proximal

ligation can be used if the contralateral vertebral artery is intact.

! Internal Jugular: Repair vs. ligation.

Esophageal Injury:! Best detected by combination of esophagoscopy and

esophagram in symptomatic patients.! Injection of air or methylene blue in the mouth may aid in

localizing injuries.! Close wounds in watertight 2 layer fashion.! Controlled fistula with T-tube or exteriorization of low

non-repairable wounds! Small pharyngeal lesions above arytenoids can be treated

with NPO and observation 5-7 days! All patients should be NPO for 5-7 days.

Laryngeal/Tracheal Injury! Thorough Direct Laryngoscopy for suspicious wounds! Tracheotomy for suspected laryngeal injury

Conclusions! Mandatory neck exploration is no longer

considered acceptable! ABC’s! Physical Exam is probably the most useful

diagnostic tool.! Intervention should be directed to sites of possible

injury! Non-invasive diagnostic modalities should be

considered.